Medical History Form - University Of Maryland University Health Center Page 2
ADVERTISEMENT
1
2SEXUAL HEALTH HISTORY
Have you had intercourse? □ Yes
□ No
Age at first intercourse: _____
Number of partners in the last 12 months: _____
Number of lifetime partners: _____
Partner(s): □ Male
□ Female
□ Both
Do you use condoms or other STD/STI prevention methods? □ Always
□ Sometimes
□ Never
Have you or your partner ever used birth control? □ Yes
□ No
If “yes”, what type(s) of birth control(s) have you used in the past? ___________________________________________________
□ No
□ Unsure
Have you had any history of the following STDs/STIs?: □ Yes
(please circle below)
Gonorrhea, Chlamydia, Genital Herpes, Genital Warts, HIV, Trichomonas, Hepatitis B, Hepatitis C, HPV, Other: _________________________________________
Do you have any questions/concerns about your sexual health? _________________________________________________________
Are there any areas of health or well-being you would like to discuss? ___________________________________________________
The information provided is accurate to the best of my knowledge.
SIGNATURE: ____________________________________ DATE: ___________
FEMALE PATIENTS ONLY
MENSTRUAL HISTORY
Age menstrual periods began: _____
Menstrual periods come every _____ days
Number of days of menstrual flow _____
Consistency of menstrual flow □ Light
□ Moderate
□ Heavy
Do you think you might be pregnant now? □ Yes
□ No
□ Maybe
Have you ever:
□ Yes
□ No
Had missed periods?
□ Yes
□ No
Had bleeding in between periods?
□ Yes
□ No
Had pain with periods (menstrual cramps)?
□ Yes
□ No
Taken medications for pain? If “yes”, which medications? ____________________________________________
□ Yes
□ No
Had other premenstrual symptoms? If “yes” which symptoms? ________________________________________
GYNECOLOGICAL HISTORY
Have you ever:
□ Yes
□ No
Had a pelvic exam? If “yes”, what is the date of your last exam? _______________________________________
□ Yes
□ No
Had any vaginal infections (yeast, bacterial vaginosis, etc.)? __________________________________________
□ Yes
□ No
Had any pelvic infections (uterus, fallopian tubes, ovaries, or PID)? ____________________________________
□ Yes
□ No
Had other problems with your uterus, fallopian tubes or ovaries (fibroids, tubal pregnancy)? _________________
□ Yes
□ No
Had pain or bleeding with intercourse? ___________________________________________________________
□ Yes
□ No
Had abnormal pap smear(s)? If “yes”, what are the dates? ____________________________________________
PREGNANCY HISTORY
Have you ever been pregnant? □ Yes
□ No
Age at first pregnancy _____
Number of pregnancies _____
Number of live births _____
(Number of full term births > 37 weeks _____
Number of premature births < 37 weeks _____)
Number of miscarriages _____
Number of abortions _____
Number of living children _____
OFFICE USE ONLY
Reviewed by: ___________
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Medical